(a) A health benefits plan shall permit a member with chronic disabling or life threatening conditions to choose a health care specialist as the member's primary care provider. The specialist must be a participant in the health benefits plan and be available to attend to the member.
(b) A specialist chosen by a member pursuant to subsection (a) of this section, shall be permitted to treat the member without the member first receiving a referral from another health care provider. The specialist may authorize referrals, procedures, tests, and medical services subject to the terms of a treatment plan developed by the specialist and approved by the insurer.
(c) A health benefits plan shall permit a member with a chronic disabling or life threatening condition to have direct access to a specialist qualified to treat the condition, subject to initial referral by the member's primary care provider and a treatment plan approved by the member's primary care provider. Such treatment plan shall ensure that the member will receive covered medically necessary procedures, tests, and medical services.
(Apr. 27, 1999, D.C. Law 12-274, § 201, 46 DCR 1294.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 32-572.1.
Legislative History of Laws
For legislative history of D.C. Law 12-274, see Historical and Statutory Notes following § 44-301.01.
(a) In general, subject to subsection (b) of this section, a health benefits plan shall permit a member to receive medically necessary or appropriate specialty care for more than one visit without having to obtain the insurer's approval for subsequent visits authorized by a primary care provider.
(b) Subsection (a) of this section shall not apply to specialty care if the insurer informs the member, orally and in writing, of any limitation on the choice of participating providers with respect to such care.
(Apr. 27, 1999, D.C. Law 12-274, § 202, 46 DCR 1294.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 32-572.2.
Legislative History of Laws
For legislative history of D.C. Law 12-274, see Historical and Statutory Notes following § 44-301.01.
(a) Every health benefits plan that requires or provides a member with the opportunity to designate a participating primary care provider, shall permit a member who is female to designate as her primary care provider a participating physician or advance practice registered nurse who specializes in obstetric and gynecology.
(b) If a member who is female does not designate a participating physician or advance practice registered nurse as described in subsection (a) of this section as her primary care provider, the health benefits plan may not require authorization or referral by the member's primary care provider, or otherwise, in order for the member to receive routine obstetrical or gynecological services from a participating obstetrician or gynecologist or advance practice registered nurse described in subsection (a) of this section.
(c) For the purposes of this section "routine obstetrical and gynecological services" means the full scope of medically necessary services provided by the obstetrician or gynecologist or advance practice registered nurse described in subsection (a) of this section in the care of, or related to, the female reproductive system and breasts and in performing annual screening and immunizations for disorders and diseases in accordance with nationally recognized medical practice.
(d) Nothing in this section shall prohibit an insurer or Health Maintenance Organization from requiring a participating obstetrician or gynecologist or advance practice registered nurse as described in subsection (a) of this section to provide written notification to the covered female's primary care physician of any visit to such obstetrician or gynecologist or advance practice registered nurse. The notification may include a description of the health care services rendered at the time of the visit.
(Apr. 27, 1999, D.C. Law 12-274, § 203, 46 DCR 1294.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 32-572.3.
Legislative History of Laws
For legislative history of D.C. Law 12-274, see Historical and Statutory Notes following § 44-301.01.
